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Body image is a merging of one’s outer appearance with perceptions derived from
personal and cultural factors1; body image is a “multidimensional construct that is
influenced by biological, psychologic, and social factors.”1 Thus, an adolescent
constructs her or his body image in many ways, incorporating input from family,
peers, and media.6 Pressure to emulate the Western body ideal, ultra thin for women
and muscular for men, comes from parents, friends, and the media (see Fig 1).
*Corresponding author.
E-mail address: vstrasburger@salud.unm.edu (V. C. Strasburger).
Copyright © 2008 American Academy of Pediatrics. All rights reserved. ISSN 1934-4287
522 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
Fig 1. A, Anna Kournikova ad for sports bras. A former tennis star, Anna Kournikova never won a
major tennis tournament in her career yet outearned the Williams sisters because of her status as a sex
symbol. B, “Are You Hot?” Men are frequently featured in the media for their muscular development.
influenced the development of concerns about weight and the initiation of weight-
control practices.6 An Internet-based eating disorder prevention program conducted
with 455 college women found that parental negative comments about weight or
shape was associated with lower self-esteem.7 Overweight teenagers are teased more
often and are at greater risk of dissatisfaction with their bodies.7–9 Whatever the
source of the comments, negative or teasing statements about weight “contribute to
the development of excessive weight and body shape concerns, which is a risk factor
for the development of eating disorders.”7 Teenagers believing that weight status is
important to their mothers were more likely to think frequently about being thinner
and about dieting in a large cross-sectional study of 11- to 18-year-old girls and
boys.10 Overt messages from parents encouraging their daughters to lose weight
predict an increased drive for thinness and higher likelihood of body dissatisfaction;
direct messages were more influential than parental modeling of dieting behaviors.11
The media (discussed in more detail later) clearly exert influence on body image (see
Fig 2). Perhaps media, functioning as a “superpeer,”19 define the look and body shape to
attain via images available to all teenagers in many venues, whether magazines, television
programs, or film. “Hey, kids, this is the way we all should look!” Teenagers today
face a growing discrepancy between their bodies and mediated role models.
Fig 3. The prevalence of obesity continues to increase in the United States. Among adults, more are
overweight or obese than normal weight.9
Adolescents confront daunting tasks as they move through puberty toward adult-
hood. Establishing a healthy, positive view of one’s body is key to a successful
transition. Researchers have found a wide array of harmful emotional outcomes
associated with negative body image, including depression and poor self-esteem.28,29
Today’s adolescents live in a world surrounded and defined by media.30 They are
heavy users of media (see Fig 4),31,32 many of which proffer unhealthy and unreal-
istic body images for adolescent viewers. Television, Internet, music videos, maga-
zines, and movies all feature unrealistic, unattainable icons of beauty and desirability.21
Magazines aimed at female teenagers are extremely popular and have increased
in number and availability. An estimated 33 million adolescents spend more than
$175 million annually on these magazines; content heavily emphasizes clothing
and fashion, appearance, and dating.33 Teen-oriented magazines draw readers
into articles and photographs, and some believe that the ultra-thin, ideal images
in magazines are more accessible and believable to teenagers than those in other
media, including television (see Fig 5).30
The research says “yes.”34 Media images and messages offer powerful cues
about how we need to look, what we need to eat, and what we must buy. Whether
on the television, movie screen, or the front page of teen-focused magazines or
People, we see graphically which bodies are beautiful, which shapes are “hot,”
and who is successful or not (see Fig 6). We suffer through headlines about
which young star is admitted to an eating-disorders program and who looks best
in a bikini this season. For adolescents grappling with emerging pubertal
changes, comparing themselves to the stars of stage and screen is unavoidable.
Fig 4. A, In a typical day, percentage of 8- to 18-year-olds who spend more than 1 hour watching
television, listening to music, etc. B, Which media young people use.
Fig 4 (continued). C, Differences in media use according to age. D, Relationship of bedroom media
to time spent using media: a snapshot of preteens’ and teens’ media use. Teenagers spend more time
with media than in any other leisure-time activity except for sleeping. (Copyright Kaiser Family
Foundation. Used with permission.)
528 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
Others have suggested that situation comedies add to this dilemma, because thin
female characters receive significantly more positive verbal comments from male
characters than do heavier characters.45,46 A 1999 study reinforced the primacy
of the thin-ideal female in television programs that are popular with young
M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546 529
viewers. The thin females won positive comments from male characters; but the
more female characters were dieting, the more they made negative comments about
other women’s bodies and weight, consistent with low self-esteem.47
Fig 8. Trend in BMI of Miss America Pageant winners, 1922–1999. The gray horizontal line
represents the World Health Organization’s BMI cutoff point for undernutrition (18.5). (Reproduced
with permission from Rubinstein S, Caballero B. JAMA. 2000;283:1569; copyright © American
Medical Association.)
aimed at adolescent girls more than tripled, and a majority of 15- to 18-year-old
girls reported reading these magazines daily.52 Studies have shown that girls
reading these fashion magazines compare themselves to models in the ads and
articles and have more negative feelings about their own appearances.26,53,54
and found that the body weight of these women was 13% to 19% below
average.50,55 The BMI of aspiring Miss America contestants has declined from
22 in 1922 to ⬍18 in 1999, the latter BMI indicating undernutrition.56 Almost 20
years ago, adolescent girls described their “ideal girl” as an almost impossible 5 feet
7 inches tall, weighing 100 lb, and with long blond hair and blue eyes57 (see Fig 8).
“Evidence is increasing that there are tremendous pressures on today’s girls and
young women to try to attain body shapes that are unhealthy, unnatural, and
dictated by media norms.”35 Many scholars believe that this “internalization of
the thin-ideal body image” has resulted in females in America being increasingly
dissatisfied with their bodies, possibly leading to eating disorders.6,34,36,37,58 – 60
A 2004 study revealed that even movies aimed at a young audience, Cinderella
or The Little Mermaid, for example, contain body-image–related themes.61 A
disturbing study in Australia revealed that of 128 children aged 5 to 8 years,
many wanted to be thinner by 6 years of age.62 In 2007, Australian researchers
tested 265 primary school girls to determine if the importance of appearance
relates to body dissatisfaction. They found that exposure to media and peer
influence were negatively related to body esteem.63
Popular television comedies, including Ally McBeal and Friends, soap operas
(popular with adolescent girls), music videos, and films aimed at teenagers may
expose viewers to potential role models who actually suffer from eating disorders
themselves.34,37 In a critical twist, overweight female characters tend to be
criticized by male characters, whereas overweight male characters may make fun
of themselves but do not engender negative comments from others.47 A study of
837 ninth-grade girls found that the number of hours watching music videos was
associated with their feelings about the importance of appearance and their
weight concerns.66 Similarly, girls watching a music video that emphasized
appearance had more body dissatisfaction than those watching a neutral video.67
Clay et al53 found that exposing young girls to thin or average-sized models in
magazines lowered self-esteem and body satisfaction. The authors of 3 meta-
analyses68 –70 examined the association between media exposure and body dis-
satisfaction; only one study revealed no association.70
M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546 533
There are 4 key components to the theory that media images and messages do
influence the body image of young viewers.71
1. Although the “ideal” woman has gotten increasingly thinner over the past 2
decades, the real woman has actually gotten heavier.40,56
2. Thinness has become associated with social, personal, and professional success.72,73
3. Especially for teen girls, the thin look has become normative,35,73,74 which
could relate to the superpeer concept.19
4. Adolescent girls and grown women have been led to believe that thinness can
actually be attained easily.35,74
In 1997, Signorelli73 conducted a content analysis of girls in the media and made
several relevant observations. Teen-oriented shows featured advertisements us-
ing beauty as a product appeal in 56% of ads targeting females and 3% of ads
targeting male viewers. Fully 56% of female characters in movies had their looks
remarked on, and 70% of girls wanted to look like a television character
(compared with 40% of boys). Half of those girls did something to change their
appearance as a result. Women are often caught up in the trap of living in a
culture in which they are expected to be the objects of the male gaze, but then feel
the need to compare favorably with ultra-thin role models.75,76
In a recent review, Cohen30 reviewed the current literature and examined the
social-comparison theory78 but also introduced the relevance of Gerbner’s cul-
tivation theory80 in the context of body dissatisfaction. The cultivation theory
534 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
simply “predicts that people who are more exposed to greater degrees of televi-
sion will have attitudes that are more reflective of media realities, and less
reflective of real-world social realities.”30 The author gave the apt example of an
ultra-thin woman on television consuming junk food and not exercising; “in-
complete information about the link between diet and fitness are communicated
with the viewer.”30 She concluded, “Media exposure does seem to have an
impact on body dissatisfaction, disordered eating, and drive for thinness.”30 The
relationship is stronger for magazines than for television, both of which are
“thin-depicting” media, but the former is a more engaging pastime.30
One study of college women showed that those who were concerned about their body
shape judged thin celebrities as thinner than they were; however, those comfortable
with their body shape judged the celebrities accurately.81 Field et al74 conducted a
series of studies using a large database of 6770 adolescent girls aged 9 to 14 years.
Girls wanting to look like characters on television, in movies, or in magazines were
twice as likely to be concerned about weight, become constant dieters, or engage in
purging behaviors.6,14,74 A longitudinal study revealed that television viewing pre-
dicted thinner ideal body shapes and disordered eating 1 year later among 257
preteen girls,82 and a recent study of 11 000 adolescents, both male and female,
found a concerning correlation between wanting to look like media role models and
being more likely to use anabolic steroids or unproven protein supplements.26
Surveys have revealed, despite the participants’ actual body weight, exaggerated
fears of obesity among adolescents.88,89 Viewers trust media, especially televi-
sion,90 but media portrayals of the ideal woman are distorted, especially with
today’s rising rates of overweight and obesity. With few exceptions, notably
Rosanne Barr years ago and Queen Latifah more recently, there is a dearth of
successful, charismatic overweight female media role models.34
In 1985, the BBC banned televising beauty pageants, labeling them “an
anachronism.”91 In the world of high fashion, the use of ultraskinny models is being
scrutinized, and in some situations models have been banned from the fashion
runway.92 American media seem obsessed by the ups and downs the weight of
popular film and television stars and models; “whether this degree of publicity about
actresses’ (and models’) body weights is healthy or harmful remains to be tested.”34
Everyone follows Oprah’s struggles with weight vicariously.
Is Everyone Susceptible?
Body image and dissatisfaction with one’s body vary across ethnic and racial groups
in America.1,79 Specifically, black female adolescents are “more tolerant of adipos-
ity,” and Asian American college-age adolescents are less so.93,94 However, black
young women who are dissatisfied with their body image may be at increased risk for
unintended pregnancies and sexually transmitted infections.95 One study revealed
that ethnic identity did not mitigate the relationship between depression and body
dissatisfaction for females,29 and a 2006 study suggested little difference in body dissat-
isfaction among women self-identifying as black, Asian American, or Hispanic.96
There has been little research on factors of personal characteristics that may enhance
body satisfaction. Some studies have suggested that positive relationships with
parents or feeling supported by surrounding social network are likely buffers.97–99
Presnell et al speculated that “theoretically, cognitive factors such as attributional
style or perceived control, which have been linked to depression and anxiety, may be
associated with body dissatisfaction.”97 More research on resilience and protective
factors for positive body image is needed.
Similar to other harmful effects of media, including violence, heavy viewers and
users of the plethora of media types may be at greater risk for body dissatisfaction
simply because they see more images. More research is needed on vulnerability: which
children and teenagers are at greater risk of internalizing media images and messages?
Although the bulk of research has involved females, males are clearly not immune
to mediated images and messages. More research on male children and teenagers is
536 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
needed.3,4,6,87 One study of boys’ action figures (often featured on television shows)
between 1964 and 1998 found that the characters all had smaller waist sizes with
ballooning chests and biceps.100 Boys are more interested in bulking up, not weight
loss.44,75 In a study of ⬎10 000 adolescents, Field et al26 found that 8% of girls and
10% of boys reported using substances to enhance muscle mass, appearance, or
strength. Boys used the substances to bulk up muscle, but girls also reported a desire to
lose weight. Both genders were more likely to use substances if influenced by the
appearance of models in the media: “concern with muscle definition and media images
may lead young people to use unhealthful products to achieve a more desired
physique.”26 Boys seemingly possess sociocultural ideas that are different from young
women. However, the increasing epidemic of overweight and obesity in all age groups
and both genders may change these observations. The heavily publicized use of anabolic
steroids in baseball and other sports venues may influence adolescents, particularly young
men. A 1999 review revealed that young males are often dissatisfied with their bodies, not
because they are not thin enough but because they want to be both lean and muscular at
the same time. Some boys are concerned about weight loss; “there is evidence that boys
are divided between those who desire to lose weight and those who wish to gain weight
and musculature.”101 Girls uniquely strive for thinness, but “there may be 2 pathways to
body dissatisfaction among boys—weight concerns and muscularity concerns.”101 How-
ever, both genders aim toward a media-dictated body-image ideal.
As startling as the research discussed above seems, the existing studies do not
yield a simplistic “yes” or “no” answer to the question of whether media
exposure causes eating disorders. “Probably the most conservative view is that
there is now considerable evidence that the media influence body image and
self-dissatisfaction among young girls and women”34 (see Fig 9). At the same
time, several cross-sectional studies have revealed an apparent link between the
level (and type) of media exposure and the likelihood of having an eating
disorder or symptoms of disordered eating.14,71,102–106
The Internet, often a valuable learning tool, is also a minefield of dangerous infor-
mation for the weight- and body-image– conscious teenager. A recent study identi-
fied at least 20 proanorexia Web sites that offer encouragement for disordered eating
behaviors.114 “The general attitude of the pro-ana (anorexia) and pro-mia (bulimia)
sites is one of superiority, empowerment, and pride, where young women encourage
one another to demonstrate self-control and reject weak societal values.”115 These
unmonitored sites clearly represent a danger to vulnerable, possibly seriously ill
young people; typical visitors on these sites are overweight young women and others
who have eating disorders or other mental health problems.1
538 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
A naturalistic study reinforced concerns about the connection between media exposure
and eating disorders. Three years after the introduction of American television to the
island of Fiji, 15% of girls reported vomiting to control weight. Before the introduction
of American television shows, only 3% were dissatisfied with their weight or appearance.
The number of Fijian teenagers who scored high on a test for disordered eating doubled,
and 75% of the girls reported feeling “too big or fat” after mainstream American shows
such as Beverly Hills 90210 came to their country. Those girls watching television ⬎3
nights per week were 50% more likely to have negative body image and 30% more likely
to diet.116 Similarly, a recent longitudinal study of 3000 Spanish adolescents over 19
months found that those who read fashion magazines were 2 times more likely to
develop an eating disorder.117 The very young are not immune either. Harrison103
studied 300 children aged 6 to 8 years at 2 schools in the Midwest and found a
correlation between television viewing and eating-disorder symptoms.
Not all researchers have found an association between exposure to certain media
images and eating disorders.118 –122 Some studies have revealed one media
subtype to correlate with abnormal eating habits but not others (eg, fashion
magazines, music videos, and soap operas but not television in general).119,123
These findings could relate to sometimes unreliable self-reporting of media
exposure by subjects or to the “third person effect” (teenagers are known to be
susceptible to the belief that “media affects everyone but me”).124
The media could certainly play a role as a catalyst or intermediate influence, rather than
a direct and complete cause of eating problems, perhaps only by certain subgroups of
young women.125 It is highly likely that media images and messages contribute to the
construction of a young women’s body image, often negative.35 In turn, a negative body
image occurring during early adolescence may make disordered eating more likely.126
Until these associations are examined further, adults must make media healthier for
young viewers and users of the increasing array of media today.
Media education presents the best opportunity to counter the harmful messages
and images on large and small screens and in the print media. Media education
involves teaching young people to be savvy, wise consumers of all media.
Media-educated teenagers learn several lessons127,128:
● Media have political, social, and economic implications.
● All media are constructed for a reason.
● Media contain ideological and value messages.
● Media construct our culture.
● Each form of media uses its own language and techniques.
● No two people experience media the same way.
Fig 11. Dove has successfully countered the traditional advertising of women by using full-sized
models in their ads.
540 M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546
As daunting as the prospect seems, engaging the media to provide healthier messages
about body images must be a key component of improving media for young people.
Fig 12.
M. J. Hogan, V. C. Strasburger / Adolesc Med 19 (2008) 521–546 541
Ads that feature normal teenagers and shows that feature normal teenagers of all
shapes and sizes could go a long way in reorienting body image toward normalcy
(see Fig 10). Consumer complaints about magazine ads and articles and television
programs should be encouraged. Not surprisingly, other countries are more attuned
to the media’s role in body-image formation (eg, Great Britain).35 Ideally, shows,
articles, and advertisements would depict healthy nutritional choices and exercise as
the hallmarks of good health. Occasionally, examples of positive, believable, non-
skinny media characters do appear: the 2002 movie Real Women Have Curves depicted
an overweight Hispanic teenager played by America Ferrera, who is also featured in the
teen movie The Sisterhood of the Traveling Pants and the television hit Ugly Betty.
Pediatricians and public health leaders must continue to recognize, prevent, and treat
obesity and eating disorders. Many professionals are viewing the epidemic of obesity
as one of the primary health concerns facing children and youth. Acknowledging the
role of media in influencing the escalating rates of these problems is key. The new
American Academy of Pediatrics guidelines for preventing obesity and its compli-
cations in childhood and adolescence recommend limited media use daily as part of
a comprehensive management plan.130 In addition to healthy dietary choices (em-
phasizing fruits and vegetables) and 60 minutes of vigorous exercise daily, media use
is clearly recognized as a contributor to the obesity epidemic. In a staged approach
for children with a BMI between the 85th and 94th percentiles, screen time should be ⬍2
hours daily as a preventive measure. For children and adolescents requiring a structured
weight-management protocol, the total screen-time recommendation is ⬍1 hour daily.130
CONCLUSIONS
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